MEDICARE: MALAR KUPPAN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	AP11701	AZ
2	363LA2200X	Adult Health Nurse Practitioner	AP11701	AZ
3	363LG0600X	Gerontology Nurse Practitioner	AP11701	AZ
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP11701	AZ

General Provider Information

NPI Number	:	1295216190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALAR KUPPAN NP

Provider Business Mailing Address
First Line	:	5519 W BANFF LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-3045
Country	:	US
Telephone Number	:	623-261-5258
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 W THUNDERBIRD RD STE 202
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-4712
Country	:	US
Telephone Number	:	623-301-9992
Fax Number	:	623-432-7006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2018
Last Update Date	:	03/13/2025

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